Book reviews

AVe have great pleasure in noticing the progressive state o* tliis Society. The first number of its papers, containing a selection of important communications, was published in 1790The second, from want of funds, did not appear till 1S06A third, forming the first volume, "was printed in 1S0S ; the first part of the second volume was published in 1809, which this number completes ; and from the increasing respectability of the Society, a volume may, in f uture, be expected annually. i

pecting the earliest physicians in the state, notwithstanding the establishment of Harvard university in 1638, and the various records and traditions of that period. The first medical publication appeared in 1677, and is entitled, " A Brief &uide in the Small-pox and Measles," by Thomas Thatcher, a Clergyman and Physician. About the same time was published , without the author's name, a Letter concerning a good Management, under the Distemper of the Measles.
The beginning of the next century was memorable for the controversies excited by the introduction of variolous inoculation in Boston, by Cotton Mather, a celebrated divine.
Most of the clergy strenuously supported the novel practice.
Amongst the most sturdy opponents were Lawrence Dal-I'ound, a Frenchman, and Dr. Douglas, a native of Scotland ; whilst the writing of Dr. Boylston had great influence in establishing inoculation. " His experiments commenced With his son in 1720, and in a year he extended the diseaseto 247 persons, of whom but six died." Besides the tracts on measles and small-pox, during a century ail(i a ]iaif? the only other medical publication, was a tract on pharmacy, written in 1732, by Thomas liar ward, a clergyman. A1 he first medical establishment was an hospital at Rainsford's island, in the harbour of Boston, which, for upwards a century, has been appropriated to the reception of farmers and others with " contagious sickness." Hospitals j?r inoculation were opened in the vicinity of Boston in 1764; and in a few years afterwards, at various other places. " The first information of physicians in an associated capacity, is in the preface to Douglass, which is addressed to a medical society in j?ston; but there are no particulars respecting it. A gentleman lately 'deceased, whose memory'included a retrospect of sixty years, and who new the author, had no recollection of its existence. ^ 1771 an anatomical society existed at the university, ^iid " held private meetings for a discussion of medical and Physiological questions, and were in possession. of a skeleton; but their demonstrations were confinbd to the dissection of appropriate animals, as the examination of the hu-Ulan body was then an extraordinary occurrence with our 111 ?st inquisitive anatomists." " The establishment of military hospitals afforded extensive oppoi"" tunnies for observations and experiments ; important operations in surgery were rendered familiar; whilst the diseases and casualties of camps were constantly occurring. Anatomy was greatly improved by 3 frequent inspection, without fear of detection, of the organs of the human body ; physiology was more accurately comprehended, and a laudable spirit of inquiry was assiduously cultivated." In 1780, the first course of anatomical lectures in this commonwealth, with dissections and demonstrations, was delivered by John Warren, Surgeon of the Iiospital at Boston.
The Massachusetts Medical Society was established in 1781 j and soon acquired a high degree of consequence in the state; for we find, that in 1789 it " was authorized to point out and describe such a mode of medical instruction, might be deemed requisite for candidates, previous to examination." " It was then determined that every pupil should have a competent knowledge of Greek, .Latin, the principles of geometry, and experimental philosophy; and that the period of instruction should in no case be less than three years, with attendance on the practice of a respectable physician* Publications are made triennially of authors to be studied by which the most valuable modern productions are extensively circulated. The censors meet for examining and licensing candidates once in four months." In J803 the constitution of the Society was essentially, changed, and its power and privileges extended by an act ot the legislature. In 1808, a Pharmacopoeia of the Society was published, after the plan of that adopted by the Edinburgh College.
The medical school! at Harvard University, from ouf author's description, promises to rival the most celebrated i'1 Europe, and has already produced several able physicians.
The improvement of our art is slow and hardly perceptible ; but when we reflect on the changes which have occurred in it during the course of the last century, the advance is ob' yious.
" In May, 1682, notice ^as given in a London gazette, that as the weather was growing warm, his majesty would not touch any more f01-* No candidate can be admitted to an examination after June 4, unless he has studied with, and attended the practice of a fellow or honors'j member of the Society. By Laws, p. 18,13. j f Ail account of this Institution is inserted in the Medical'and Philosophic Intelligence of our Journal for the present month. e Massachusetts Medical Communications. 217 the king's evil, till after Michaelmas ; and, in 1687, an indigent citizen New Hampshire, having tried every other means without effect, petitioned the legislature for aid to transport him to England, for that efficacious remedy.'' file Massacliuse Is Humane Society, founded in J786, was incorporated in 1791, and has 587 members.
Since the year 1799, vaccination lias been practised in the stale with considerable success, and institutions have been appointed to aid its progress.
Besides editions of ancient and approved medical works, scarcely a publication of importance issues from the British press, without being shortly reprinted, and extensively circulated in America.
We have thus taken a rapid sketch of Dr. Bartlett's interestingdissertation; it has convinced us that the spirit of inquiry which animates our transatlantic friends, will not sutler them to rest satisfied with imbibing their medical principles from European sources ; they have now universities, professors, and libraries ; enjoy legislative protection, and have perfect freedom from those restrictions and impediments to science, which enacted in a less enlightened age, continue to limit the utility of some of our public institutions.
The article which is placed first in the present number, and to which we now solicit our readers attention, is a Report respecting a Disease commonly called Spotted or Petechial Fever, which has within a fezoyears been epidemic in various parts of Nero England. A Commit'ee* was appointed by the counsellors of the Massachusetts Medical Society, at their special meeting, March 27th, 1810 3? li To frame a series of questions respecting the causes, history, and njode of treatment of the disease now existing in some parts of this commonwealth, commonly called spotted or petechial fever, to address copies of the same to the physicians who reside in places where the dis-e^se has prevailed, or does now prevail, and to request the most speedy and minute replies to the same." The report before us is the result of the exertions of this Committee. The questions framed on the occasion, were highly judicious, and calculated to direct the practitioner in his iuquirv concerning the nature of a disease which excited considerable alarm throughout New England. It first appeared in the winter and spring, chiefly in the cold months, 1,1 an inland and elevated country, abounding with hills and Vallies, ponds, running streams, and fresh water rivers. * The names of the committee are, Thomas Welsh, James Jacks, ?*nd J. C. Warren. " In Cambridge-port, the first place near t'ne sca-coast, ,it which it Was observed, it was confined fcr the most part to the land which was recently salt meadow, and which is now intersected by many foul ditches. In Boston this disease, as also typhus, has occurred most frequently in those parts of the towft exposed to the flats and water." The disease in a large proportion of cases was mild ; in some severe ; and i'1 few ?destroyed life suddenly like the plague. Whether severe or mild, " the symptoms differed only in'degree, not in kind." The communications made to the committee related chiefly to the disease in its gravest forms ; from their abstract we selcct the following particulars of its history. " The invasion of the disease is generally sudden and violent. Tn its course all the functions of the body are more or less interrupted, and often some of them are entirely suspended. The subject of it is seized in the midst of his usual labour or occupation, and oftentimes is stiuclc down suddenly, almost as by a stroke of lightning. The first symptoms are various, such as local pain or paralysis, delirium or coma, and rarely spasms or convulsions. " The disease often commences with shifting pains. The patients > suddenly feel a pain in one joint or one limb, often in a finger or toe, in the side, ttomach, back, neck, or head. Sometimes the sensation is like the stinging of a bee, frequently it is most excruciating pain, which at once arrests and commands the whole attention. This pain moves from place to place without losing its violence, generally approaching the head, and is often confined to one side of the bodv. It is said that the left side is more frequently affected than the right. The head is more frequently first affected with pain than any other part; and when not affected at the first moment, it almost invariably becomes so in a short time. The pain in the head is oftentimes intolerably severe, so that it is compared to the beating of Hammers upon the part; and the patient says he shall become crazy if it continues. " Partial loss of sensibility and paralysis are, in other cases, the first symptoms, and often occur in the course of the disease, when they do not in the beginning, The powers of sight are affected in various degrees from a slight dimness to absolute blindness." The sensibility of the skin also is diminished, so that a limb is numbed, " or feels as if it had been asleep," " In the muscles of various parts, paralysis has been occasionally observed ; as in those of one hand or foot, and oftentimes in those subservient to deglutition. In some cases hemiplegia has occurred at the commencement; and it is particularly worthy of remark, that often the greatest weight of disease falls on one side of the body ; insomuch that not only the voluntary muscles, but the vascular system has been much more affected on one side than on the other, " Not rery rarely the disease commences with delirium ; and very frequently this symptom follows a violent pp.in in the head in a very early stage of the disease. The delirium is often mild ; in some casest however, where it is attended v/ith flushed face and eyes, great heat in the head, and violent pulsation of the carotid arteries, it produces a --fury fury which is scarcely to be restrained. In a few instances the patient has become blind and raving within half an hour after the attack." Stupor, coma, convulsions, and spasms, though more frequent in the latter stages,--occasionally attend tfie accession ?'1 the disease ; and in whatever form it commences, great prostration of strength speedily ensues. " In some instances the patient is described as almost immediately killing down tinder the weight of disease. This prostration is accompanied or followed by universal or partial chills ; the skin becomes dry 3nd pale, or mottled like one who has been long in the cold ; eyes' glassy, nose contracted, the face sublivid, with paleness around the Wouth, and the countenance expressive of the utmost anxiety and distress, or its features dissolved with a loss of all character and expression ; the whole body becomes cold, respiration very laborious, especially. in children, pulses very small and feeble, slow at the commencement, but shortly very frequent. If there be neither coma nor delirium* the spirits are very much dejected, the patient suffers extreme solicitude ar>d anxiety, with apprehensions of death, frequent vighs, restlessness, and agitation. He complains of oppression and faintness, with indiscribable distress about the praecordia, and a sensation of fulness at the stomach. Frequently eructation, nausea, and vomiting ensue, and a)so fainting in the early stages of the disease ; and the vomiting occasionally becomes incessant, embarrassing and defeating every effort to give relief by internal medicines, while it exhausts the patients." The different stages of the disorder have not been accurately distinguished. Diaphoresis usually occurred at an early period, and was loll owed by a mitigation or subsidence of the symptoms. It is doubtful whether this favour-?*me event was the effect of art, or was a natural termination "pf the disease.' in general the symptoms became modified in the course of 'toni ei^ht to twenty-four hours ; and some patients have * died within that period. The second stage may be said to commence, when the pulse becomes more full and regular, (he skin warm, countenance flushed, and in plethoric subjects especially, red and florid; respiration short an I difficult, but niore regular than in the early period of the disease; eve-lids swollen and eyes staring, with a throbbing pain in, the head. Light distresses and noise irritates ; great restlessness, anxiety, and frequently delirium ensue.
J'hese symptoms usually subside, and the disease terminates "Within three days ; often in one day. Occasionally, after the severity of the disease has abated, it has continued in a Hinder form, and assumed the character of typhus, in which c^se, the termination has rarely been fatal. u Among the varieties of the disease, the following is given as a description of some cases which have occurred especially amon;*; females.
Universal deadly coldness; skin white as polished marble and smooth ; F f2 countenance 820 Critical Analysis. countenance perfectly placid ; not one distorted muscle ; pulse in the wrist imperceptible ; motion of the heart scarcely to be felt; respiration visible only by gasping, and that not frequent ; and as it were onty a step between this imperfect state of life and death.' Even from this stale of deadly stillness patients have been restored to life and health." Death rarely occurs after the third day.
" The following is a description of the termination of the disease in cases in which it was fatal within two days. After the symptoms of the second stage, as described above, have continued from six to ten hours, the skin becomes pale and cold ; pulses very quick, small and irregular ; 3'espiration less hurried, but very laborious ; countenance fallen ; the solids flaccid ; and petechial spots of dark colour, violet or livid, suddenly appear on the superior extremities, and immediately over the whole body. At length confusion of mind with constant drowsiness, inability to swallow, respiration more frequent and more laborious, with fluttering pulse, announce the immediate approach of death." The state of the skin varies considerably ; at the commencement of the disease, it is invariably dry, at a later period sweating has usually occurred with an offensive and peculiar odour. The spots on the skin differed much in different cases.
Frequently a rash or miliary eruption only appears, or a few florid or red blotch' s on the extremities. " An appearance like measle has also been noticed, and likewise vesicles and pustules, which have been compared to the vaccine and va-< riolous eruptions. In some cases these spots and eruptions have appearecl at successive periods two or thiee times in the course of the disease.
The vesicles and pustules are frequently torn by scratching ; after which or without being torn they are commonly followed by scabs of a brown colour; but occasionally they are followed by ulcerations which do not heal until after recovery These affections of the skin are often attended with itching; and independent of them, itching very frequently occurs, especially on the third day, when the symptoms become more favourable." Petechia? and vibices occur in but few cases, and indicate danger in proportion as they are dark coloured. In the majority of cases, however, whether fatal or not, there are no spots or eruptions of any kind. " The tongue is usually moist and white through the whole disease* ?when it terminates within three or five days. When it continues longer, the tongue becomes darker coloured, yellow or brown. It is sometimes very clean and red " The thirst is seldom urgent. The appetite is diminished but not entirely lost. Vomiting, but not bilious, frequently occurs.
The bowels are quiet and not readily excited to action. The ilvine discharge early in the complaint is dark, resembling tar. The urine is scanty, but not altered in appearance.

221
Wc have now enumerated the lending symptoms'ofthis, disease; for those which are occasional, or not of frequent ?ccurrence, we refer to the original publication, from which *Ve '1;ive already quoted so largely, that an apology would be r?nuisite, if (lie work could be readily obtained in this country. 1 lie appearances after death will best indicate the nature ot disease.
iQ*?on after the patient expires, and in some instances a short time "?ore, the skin assumes a formidable livid colour. This appearance is u 1e>' generally diffused over the skin, or else it exists in spots, comon!y an irregular form, but occasionally rounded. The lividity is e remarkable at fir t on the anterior parts of the subject, especially on ie ore part of the face, neck, and shoulders, than afterward ; for it gra-Ua y subsides from these to the posterior parrs of the trunk. When-^vei the cuticle has been removed by vesication, the skin is almost black n often covered with fluid blood. On the other hand, the petechia?, lcn existed during life, become paler, vesicles of phlyctentc, eruptions redness of the tunica conjunctiva dissappear." HEAD.
. cc When the cranium is separated from the dura mater, this membrane yU'% discharges a considerable quantity of blood. As soon a* the la mater is cut through, a quantity of serous fluid commonly escapes 0rn under it. The longitudinal sinus is filled with blood, and when , ounded discharges a very great quantity of this fluid, which pours into ^ lom the cerebral veins. Having raised the dura mater, we discover ] extraordinary fulness of the veins on the surface of the brain, if the c Sjtudinal -einus is still entire. This appearance, however, varies ac-^v-| !nS to the duration of the disease. In those who have perished v nn the space of twelve hours from the first invasion, the large blood-Co S. s are excessively crowded, while, in those of twenty-four hours t'^uce or longer, the minute vessels are more distinct; and the to ?r aPPearances we are to describe are more conspicuous in proportion tcrtile duration of the disease. The tunica arac'nnoides and the pia ma-,are remarkablv altered in appearance, by the effusion of an opaque s s>ce between them, which may be called coagulated lymph, or l&u 1"PUru^ent lymph. This substance is frequently of the yellowish co-g^pf pus, with a consistcnce between the tenacity of lymph, and the cha ^ ^t &t^er t'rnes ws see it possessed of the aspect of well sel lacter'Zed lymph. This effusion accompanies the course of the vesthe Senerally."?" The two hemispheres of the brain adhere to ^ aura mater, near the longitudinal sinus, and to each other with so st. strength, as to requite a laceration or incision through the subdul]Ce ?^le brain, in order to arrive at the corpus callosuin. The meof tksu^stance exhibits a great number of bloody points at the sections ter 1? VesSe's? while the cortical part seems paler than usual. The laofiai ventricles always contain a notable quantity of water : this varies at COurse. Sometimes these cavities may be seen greatly enlarged, and ieis? with not more than three or four times the quantity often found 222 Critical Analysis* found in healthy brains. The plexus choroides is often thicker harder than natural, but always very pale from maceration in thfe effused water.
The membrane attached to the plexus exhibits very considerable alterations from its healthy transparency to a state of morbid thickness and opacity. The membranes at the basis present the same appearances as at the vertex of the brain." THORAX.
" The heart generally exhibits some appearance of disease. In every instance the small vessels on the surface of the organ are beautifully injected : the external coat is sometimes the seat of a deposition of lymph J and even the inner lining ani valves are occasionally'altered from their healthy texture. The right and left cavities usually contain a small quantity of black blood, quite similar in appearance and quantity ; a"'* even the aorta has been seen gorged with the same dark-coloured fluid* The structure of the lungs is not commonly .deranged." The abdominal viscera rarely presented any marks of disease.
The latest period after death wlien those subjects were, examined " was from twenty to twenty-four hours ; at which time there was a less offensive odour exhaled from the body than during life, and there were no signs of tile commencement of putrefaction." ' * The treatment most generally pursued, was to produce early and long continued sweating. The remedies chiefly employed for that purpose were ipecacuanha; and occasionally it was combined with opium, and " cordials'''' were also freely administered. These were aided by external applications, as the warm bath, blankets, hot flannels, This treatment often proved successful, although several practitioners strongly objected to the use of the cordials, wfyich they believed were productive of much injury/ In the lethargic state, tincture of opium in large doses was very serviceable; in some cases from fifty to a hundred drops of <he tincture administered every half hour " almost invariably removed the lethargy." Arsenic was not much employed, but when used proved beneficial. " At the same time that cordials have been employed internally, ant^ heat to the general surface of the body, cold water, snow, and ice have been applied to the head. These applications have been made, whet* there was violent pain in that part with heat and Unshed face, and whert there was violent delirium. The cold applications have, iii these cases* afforded great comfort to the patient, and have mitigated or remove those very important symptoms. Sulphuric aether dropped on the head and allowed to evaporate, has produced similar good effects.". Upon consulting various writers on the Materia Medica> Mr. Moore found them ail agree in asserting that the white Hellebore is a virulent emetic and purgative. It is stated in the New Edinburgh Dispensatory, that the tincture of White Hellebore is sometimes used for Actuating cathartics, &c. " and is an emetic in apoplectic and maniacal disorders." It may likewise be so managed as to prove a powerful alterative and deobstruent in cases, where milder remedies have little effect. But a great deal of caution is requisite in its use*: the dose at first ought to be only a few drops ; if considerable, it proves violently emetic, or cathartic." Mr-Moore also perceived a striking agreement in taste between the tincture and the Eau Medicinale. From all these circumstances Ik; was inclined to hope that lie had discovered the medicine in substance though not in form, and determined to attempt the latter, by making a vinous infusion ot Hellebore, and, having filtered it, mixed some of it with tincture of opium. The mixture resembled the taste and appearance of the Eau Medicinale, but had not its peculiar smell.

Blisters
" The root of the White Hellebore is almost inodorous ; consequently, the feiiiell of any infusions of that root must depend upon the wine, or the ingredients with which it may be compounded." It then occurred to Mr. M* that Husson being a Frenchman, was likely to adopt some French form; for as no chemical analysis could detect his medicine, theonly way was to endeavour to analyse his mind.
" I therefore, (says Mr. M.) examined Les Elemens de Pharmacies par M. Beaum?, Maitre Apothecaire de Paris, and there found that the Parisian physicians had adopted Sydenham's prescription for their laudanum ; which is, an infusi6n of crude opium with saffron, cinnamon* and cloves, in Spani.-h white wine. 1 immediately procured a phial of Sydenham's laudanum, and on mixing it with the wine of Hellebore I Yound that this mixture approached very near to the Eau Medicinale in colour, in taste, and even in smell ; and when the mixture had stood for some time, these' gradually formed the same cloudy deposit which is so remarkable in Husson's medicine." The quantity of laudanum Mr. Moore calculated to be one fourth. Moore's interesting letter, from whichwe think that he has at least established au evident resemblance in appcarance, as "Wellas in qualities,between tlie two medicines. Actual experiments upon patients can alone confirm his very probable conjectures, and reasoning upon the subject. Only lour cases &re stated in the present publication, arid in these " the exacts of the mixt infusions were precisely t he same with equal doses of the Eau Medicinale. in two of the cases where two cJ"ams were given, vomiting and purging were produced ; ^?:id in one case the medicine occasioned constipation, which happens also with the Eau Medicinale; and the gout in all relieved." Since this letter was published, we hear that benefit has been obtained by the new remedy/in several other cases of gout. r To enable our readers to make trial of the medicine, we subjoin the formula as directed by Mr. Moore, and shall h?pe shortly to receive more information on this truly important subject.
' -.<c Take of white hellebore root, eight ounces; white wine, two Fnts and a halt. The root is to be cut in thin slices, and infused for ten days, occasionally shaking the bottle. Let the infusion be then filtered through paper.?The mixture employed for the gout, .consisted ?f three parts of the above wine of white hellebore, and one part of liquid laudanum. -.
We presume, the dqse should be from one to two drams of the mixture, according to the nature ol the case, or the operation of the medicine, which varies in different constitutions. Tn 1712 Anel being called to attend on the Duke of Savoy, avoided tie rule and coarse method of treating Fistula Jjachrymalis by cutting, b?ring, and burning; and introduced a slender probe into the punclum lachrymalis, and from thence into I he sac, and through the nasal duct into the nose. The obstruction being assumed thus to be removed, he proposed to maintain the opening by injecting tepid water night and morning, or oftener, by an ingeniously contrived'syringe; and repeated the introduction of the probe as often as necessary, or until the injection passed freely to the nose, and no purulent matter was discharged either spontaneously,-or!by pressar , from the lachrymal sac through the puncta. The app treut simplicity of this operation, its occasioning no destruction of parts, and its consonance to nature, gained it, for a time, many partisans. Fantoni, a physician of Turin, Mangetus, Molinetti, Lancisi, V^allisnieri, Morgagni, and Heister, were its panegyrists: but it was very early opposed by F. Signorotti, who published a work expressly against it*; and our countryman Mr. Pott observed* u the passing of a small probe through the puncta has a plausible appearance, but will, upon trial, be found very unequal to the task as-; signed: the very small size of it, its necessary flexibility, and the very little resistance it is capable of making, are manifest deficiences in the instrument; the quick sensation in the lining of the sac and duct, and its diseased state, are great objections on the side of the parts, supposing that it was capable of answering any valuable end, which it most certainlyis not." ; ; Inadequate as the method of Ariel was, it had the merit of being founded on a knowledge of the structure of the parts, and in this view led to an improved practice. It was now Understood that the disease in the lachrymal sac was occasioned by an obstruction in the ductus tidnasum, and all subsequent efforts were directed to restore that passage to its natural state, or to supply it by an artificial opening. To reestablish ihe natural passage, Mtjan introduced a seton from the nose into the nasal duct, by means of a needle armed with * Those of our readers who may have the curiosity to search into the history of an ob olete, though perhaps, not totally useless practice, we ref r to " Observation singuliere sur la fi>tule lachrymkle, dans laquelle on appendra la merhode de la guerir radicalement. 4to. Turin ; 1713*'-Nouvelle meth >de ile guerir les fistules lachrym.iles. 4to. Turin. 1713-Suite de la niuvt.de methode de guerier la fistule lachrymale. ,4to.
Turin. 1714." And a " Dissertation fsur la nouvoile decouverte de I'hydropisie du conduit lachrymal. J2mo. Paris. 1716." ; a silk Dr. Rcade on Epiphora, 8?c. 229 H silk thread passed from the punctual into the cavity of the Nostril. The difficulty of getting the seton into the duct by this means, the irritation it produced when it was drawn in, well as that occasioned by the silk thread constantly hanging from the punctum, were insuperable objections to Mejan's project. J urine, an oculist of Geneva, attempted *? remove the difficulties which arose in the application of the seton, by pushing a trocar into the sac and so on to the ^ose : through the canula of this trocar he passed the scion. * he failures of Anel and Mejan were followed by various Methods of treating this disease of the inner canthus, all of "^hicli were now founded on a knowledge of the structure and functions of the parts: and their principle was either to restore the natural duct, and where that was impracticable, to Hake an opening into the nose, through the os unguis. From ?Laforet to Pott these are too well known to require recapitulation. M. Sebatier details them with much perspicuity ; but of his history it must be remarked, that it is lotally silent 0ri the elucidation the subject has received from English Surgeons, especially Mr. Pott. This must be referred to one or ot!?er of the following causes. M. Sabatier was influenced by Nationality, or he was ignorant of what had been done in this country. We are unwilling to load him with the disgrace of the first, and are induced to adopt the latter, because |he only Englishman he mentions is tfoo/huusc, a person better known at Paris than in London.* * His obscurity with regard to England, and the rareness of his ^0rks in L indon, may render some short notices of J. T. Woolhouse, J!ot quite unacceptable. He was born in London, was occulist to WiJ-, laiu. the Third, but resided the greater part of his life at Paris. He ad a warm dispute with Heister on the nature of cataract, and con- Critical Analysis. It will be understood from the preceding remarks, that J3i*-Reade treats of the diseases of the inner canthus of the eye under the three distinct states or gradations of Epiphora? TumorSaccitli Lachrymalis, and Fistula Lachrymal is. These lie " nosologically defines" in the folio,wing mariner : " uin Epiphora is a flow of tears, mixed with either pus or mucus, coming from the surface of the eye ard falling over the cheek, or pressed by the finger through the puncta lachrijmalia, without any manifest distinction or relaxation of the sac, and might be divided into two stages, the simple Epiphora, commonly pellucid, composed of tears and lymph ; and the muco-pumlent Epiphora, opaque and yellow, composed of tears, mucus, and pus. " The 'lumor SjccuU LacJirymalis, generally occasioned by the Epiphora, or a lodgment ol tears and mucus, sometimes mixed with pus in the lachrymal sa'c, by which it is evidently distended and relaxed." " The Fistula Lachiyrnalis, when from an over accumulation of the contents of the sac, inflammation takes place, and the sac bursts, forming a fistulous opening, through wl ich tears, mucus, and pus, are constantly evacuated, sometimes accompanied with a caries of the 0$ unguis." , Jn the cliirurgical treatment of these diseases of the lachrymal appendages, or rather the different stages of the same disease, the novel method promised 5y Dr. Reade applies to the Tumor Saccu/i Lchrymalts. It consists in maintaining a permanent opening at the upper part of the tumid, inflamed, and relaxed lachrymal sac, through which the tears, morbid mucus, or pus accumulated in that sac, are to be frequently discharged by pressure. The history of the author's own case will explain both the principle and practice, and present to our readers a specimen of the style of his pamphlet. " About ten years ago," he says, " I was attacked whilst at College, with a severe ophthalmia, which, after some time, yielded to the usual remedies ; but by degrees a distention and relaxation of the lachrymal sac took place, preceded and accompanicd by an Epiphora, soft and easily yielding. Whenever occasion required I pressed out a limpid tear, partly through the punct i, and partly through the nasal canal: however, when I neglected this for a few daysVhe tears instead of being limpid as usual, became inspissated, and put on the appearance of purulent matter, similar to the discharge in catarrh ; the paipebrje and meihomian glands were certainly inflamed from the commencement, not only of the tumefaction, but of the Epiphora. In this stage of the complaint 1 consulted Dr. Monro, sen. and several other surgeons of eminence in Edinburgh, who were of Mr. Benj. Bell's opinion, that whilst I found whatlhey called little inconvenience orpain from pressing outthe contents of the sac, 1 should not submit to any operation : for some years these symptoms remained stationary, but I must say very disagreeable. At length I experienced greater difficulty and some pain in pressing out the fluid, the sac became more distended and hard. Having read Mr. Ware's treatise, 1 determined to put myself under his care, and in May 180S, Dr. Reade on Epiphora, #c. 231 5808, after having consulted some Dublin surgeons, proceeded to Lon* ^on. Before I arrived the puncta, ducts, and sac, bccame inflamed and considerably tumified ; in some days, however, those symptoms having subsided, I applied to Mr. Ware, who having endeavoured, without success, to inject some warm water into the 'nose, made an incision into the sac with a spear-pointed lancet, and having discharged the thickened tears and mucus, he introduced a probe into the duct with very little: difficulty, and then inserted a nail-headed cylindrical stile, about an ijich and a quarter in length, through the nasal duct into the nose; in a few days [ was much pleased to find little inconvenience and no pain, being able to withdraw af>d replace the stile at pleasure* After a week, during which Mr. Ware every second day injected warm water for the Critical Analysts. flammation subsided, and the orifice became fistulous ; I then withdrew the leaden wire, and to prevent the orifice from closing, gently pressed out the tears every three or four hours ; i say gently, least pressure might induce inflammation and consequent adhesion. At present it is more than a year since I adopted this plan, and now have seldom occar sion to squeeze out the tears more than two or three times a day ; from this almost imperceptible orifice, the ductus ad nasum is perfectly free, as I have as copious a di charge from the corresponding nostril as from x the other, and my eyes are remarkably acute and sti Ong, although I am ip the habit of nocturnal study. " Since I discovered this method of cure, I operated in a similar manner on several, in all of whom it has succeeded, from which I think I am authorized to draw the following conclusions. 1st. " That the Tumor Sacculi Lachrymalis is only to be relieved by an operation, and that Mr. WareVis, at best, but a palliative one.
2d. " That the disease was neither occasioned, at least in this case and many others, by inflammation and a purulent discharge from the palpebrsc and meibomian glands, as Scarpa asserts, nor from any primary obstruction in the nasal duct, but arose from atony and distention of the sac, which being thus deprived of its healthy contractile power, allowed the tears to be collected and inspissated, thereby producing a mechanical obstruction. x Nevertheless, I by no means mean to say, the disease may not, in some instances, be occasioned by other obstructions in this duct.
3d " That a conical is preferable to a cylindrical stile, and that a small and almost imperceptible orifice in the superior part of the sac is better than either, producing no deformity, being less troublesome than a nail-headed stile placed in the corner of the eye, which is constantly liable either to fall out of the orifice, if too free, or to excite inflammation by the introduction, if too confined ; and finally, that when the sac is thus made a reservoir, by placing the orifice at the top, pressing out the tears two Or three times a day is as little troublesome as blowing the nose." Authors have often mode that complex and obscure, which in nature is simple and clear. Epiphora, Tumor Sacculi Lachrymalis, and Fistula Lachrymalis, are but symptoms of a disease which has not received a technical appellation. By an accumulation of inspissated mucus obstructing, or by inflammation contracting the ductus ad nasum, of ten we believe, in the latter case, occasioned by Erysipelas about the face, and by Sinall-pox, the exit of the tears from the eye is denied by the natural passage. The first and direct obvious effect is an accumulation of the lachrymal fluid in the eye, until it passes overthelid and runs down the cheek. This is Epiphora, a Symptom* of obstruction in the nasal duct. After a longer * Epiphora, not symptomatic of the obstructed state of the ductus ad nasum, may exist, and is connected more simply with a want ot balance between the action of the lachrymal gland, and the apparatus for carrying ?r a shorter time, influenced by altempts injudiciously made to remove the complaint, by accidents, or by idiosyncrasy, the saccus /achri/mulis becomes distended with accumulated tears, now opakc in that portion of them collected in the sac, and approaching to purulency in appearance, being mixed with the diseased mucus of the parts. Pressure on the sac, at this period, willdischarge its altered and apparently purulent contents, at the puncta laehri/malia. This constitute s the disease denominated Tumor sacculilachrymalis ; anoher symptQm of the obstructed or diseased state of the nasal duct.
At an indeterminate period, influenced also by the circumstances above stated, the distended sat cuius lachrymalis inflames, ulcerates, and opens externally. This is the famed fistula lachrymalis, for which, when the structureand functions of the part were not understood, the cautery, both potential and actual, was employed. The bones were injured often by this process ; exfoliation followed caries, the delicate os unguis was destroyed, and extensive opening into the nose wisiled, which maintained itself, and the disease was sometimes cured.
The obstructed state of the ductus ad nasum is the original complaint, and the causeof all the oilier morbid appearances, which exist but as evidence of that obstruction. They are removed by restoring the natural passage into the nose, or by making a new one through the os unguis. Modern Surgery very well supplies the means, and Dr. Reade's book may be wg off the tears which have washed the eye. Thus, certain states of mental feeling always ; the application of cold sometimes by constricting the puncta lachrymalia, perhaps ; and inflammation of the eye, bydiminishing the capacity, or closing the puncta, produce watery eye.
It is plain that this is the disease that Prof. Scarpa describes as proceeding from a purulent discharge from the palpebrae and meibomian glands. It will be seen that this variety of Epiphora will not produce that state of the sac which has been denominated Fistula lachrymalis. In this variety of Epiphora the tears cannot get into the lachrymal sac ; in that variety of Epiphora connected with Fistula lachrymalis, the tears are confined to the sac by obstructions in the nasal duct. When the obstruction is in the ductus ad nasum, disease in the sac ensues ; when the obstruction is in the puncta or duct leading to the sac, that cavity is secure. The pathognomonic mark, will be the absence or presence of accumulation in the sac. If on pressure applied to the sac, there is no regurgitation of the fluid by thq puncta, the conclusion will be, that the obstruction is above the sac: if regurgitation by the puncta follows pressure on the sac, the conclusion will as necessarily be, that the obstruction is below the sac, and in the ductus ?d nasum. usefully perused with this view. We cannot, however, admit with Dr. Reade, that the method by restoring the natural passage or by making a new one, is only palliative. If a radical cure ever occurs, this is the method by which it must be effected. But Dr. lleade's proposition is in its nature palliative only. As a dernier resource it may sometimes be convenient, but thus far and no farther can it go.
The Board of the National Vaccine Establishment must necessarily take a lively interest in whatever promotes or retards the progress of Vaccination, and in whatever tends to elucidate the actual properties and powers of that practice. "With these feelings, they could not look with indifference on the occurrence of Smalt-pox after what had been deemed successful Vaccination. Instances of this kind have recently happened in London, and the Establishment, with a candour and liberality that decidedly shews its disposition to ascertain and promulgate truth, has published a detail of two cases, which lmve come immediately under the observation of several of its members.
Those happened in the families of the Earl of Grosvenor, and Sir Henry Martin. The particulars-of the case of the Hon. Robert Grosvenor, third son of the Earl of Grosvenor, are given by Sir Henry Halford, and Sir Walter Farqulmr, who attended him, and by James Moore, esq. Director of the Vaccine Establishment, who occasionally visited the patient during the progress of the disease. , -" On Sunday, May 9.6, 1811, the Hon. Rubert Grosvenor, who was recovering from the Hooping Cough, became much indisposed and threw up his dinner. Fever followed, and he complained most particularly of excruciating pain in his back. He dwelt on this symptom until Thursday, when he became delirious, and there were observed on his face about twenty spots. He had been vaccinated by Dr. Jenner, in his infancy, about ten years ago, and the mark left in his arm indicated a perfect disease.
On Friday morning, the eruption had not increased materially in point of number, but the appearance of the spots and the previous symptoms, suggested strongly a suspicion that the disorder was the Small Pox. " Sir H. Halford had occasion to go to Windsor in the afternoon of Friday, and did not see Mr. Robert Grosvenor until the Monday following, (June 2d) but he learned from Sir W. Farquhar, who attended him most carefully during Sir Henry's absence, (and subsequently) that the eruption had increased prodigiously in the course of Friday; that-1 f Report of the National Vaccinc Establishment. 225 that on the evening of that day Mr. Robert Grosvenor began to make bloody water, and that he continued to do so until Monday morning. " On the tenth day of the disease, the pustules began to dry upon the face, which was swollen to a considerable degree, but not to the extent of closing his eyes, and was attended by a salivation which lasted several days. Petechia had occurred in the interstices of several of the spots, particularly on the limbs, and there was that particular smell from the whole frame which is remarkable in bad Cases of confluent Small Pox. " It was obvious that the first symptoms of which Mr. Grosvenor complained, were such as indicated a violent disease about to follow, and Sir Henry confesses that he entertained a most unfavourable opinion the issue of such a malady, when it was fully formed : having never Seen an instance of recovery under so heavy an eruption attended by Such circumstances. It seemed however that the latter stages of the disease were passed through more rapidly in this case than usual, and it ^ay be a question whether this extraordinary.circumstance, as well as ultimate recovery of Mr. Grosvenor, were not influenced by previous Vaccination." During the illness of Mr. Grosvenor, the other children of the Earl, who had formerly been vaccinated, were exposed to the contagion of the Small-pox, under w hich their brother "Has suffering, and were also submitted to Small-pox Inoculation without effect.
The Case of Mr. Martin is given by Dr. Heborden, who attended him with Mr. Tegart of Pall-Ma IK In the prec?ding pages of this number of our Journal Mr. Tegart has given, with much precision, the progress of this case from.
Jts commencement to its termination. it is admitted by the Board that the case of the Hon. R. Grosvenor was a case of confluent Small Pox. That the attack and progress of the disorder were attended with symptoms which almost invariably announce a fatal termination. " But they observe, that the swelling of the face which is generally ?o excessive as to close the'eye.,, and is considered as a favourable symptom, was slighter than usual, that on the tenth day the pustules began to dry upon the face, and that from that time the disease passed ^vith unusual rapidity through the period, when life is generally esteemed to be in the greatest hazard " Those who are acquainted with the nature of the confluent Smallpox, are awaie that this peculiarity cannot be attributed to the effect of Medical treatment.
The case of the son of Sir Henry Martin exhibits a mild form of distinct Small Pox, occurring after Vaccination. " In most cases of Small Pox which have succeeded to Vaccination the pustules have been observed to dry more rapidly, and the disorder has concluded at an earlier period than usual. " If allowance be made for the relati\e periods in which the confluent and distinet Small-pox complete their course, the rapid progress towards H h 2 recovery 236 Critical Analysis. recovery through the latter stage of confluent Small-pox, as exhibited in the case of Mr. Gro vencr, may be compared with the' rapid desiccation of the pustules in the 4istinct and peculiarly mild form of the disorder which is considered as Small Pox modified by Vaccination. Both forms of the disorder proceed in the usual course, the one attended with , v violent, the other with mild symptoms, till they arrive near to the height, when they appear to receive a check, and the recovery is unusually rapid. ' " From this correspondence of circumstances, the Bo?.rd are inducc4 to infer that in the case of Mr. Grosyenor which has been moie violent than any yet submitted to them, the progress of the disease through its latter stage, and the consequent abatement of symptoms, were influenced by an antivariolous efkct, produced upon the constitution by the Vaccine process.
" The occurrence of Small Pox after Vaccination has been foreseen and pointed out in the Report on Vaccination made to Parliament, by the College of Physicians, in the Year 1807, to which the Board are desirous of calling the attention of the Public ; wherein it is stated that, " * The security derived from Vaccination against the Small Pox# if not absolutely perfect, is as nearly so as can perhaps be expected from any human discovery, for amongst several hundred thousand cases with the results of which the College have been made acquainted, the number of alleged failures has been surprisingly small, so much so as'to form certainly no reasonable objection, to the general adoption of Vaccination ; for it appears that there are not nearly so many failures in a given number of Vaccinated persons, as there are deaths in an equal number of persons inoculated for the Small-pox. Nothing can more clearly de* jnonstrate the superiority of Vaccination oyer the-Inoculation of the Small-pox than this consideration ; and it is a most important fact, *vhich has been confirmed in the course of this inquiry, that in almost every case in which the Small-pox has succeeded Vaccination, whether by Inoculation or by casual infection, the disease has varied much from its ordinary course ; it has-neither been the same in violence nor 'in the duration of its symptoms, but has, with very few exceptions, been remarkably mild, as if the Small-pox had been deprived by the previous Vdccine disease of its .usual malignity.'" Wanner, was seized with fever on the^Oth of .Tune last, which proved the precursor of! an eruption oi distinct Small-pox* "i tie disease'went regularly through its stages, was accompanied with sore throat, and much general disorder. Peter Sylvester was inoculated by'Mr. Ring in 1/99, and had the disease in a most perfect manner. On the 24 tit ot June last this boy was seized with fever, and on the 2/th the "variolous eruption appeared. It proved a distinct but severe case of Small-pox. ' John Godwin, born in 1800, had the Small-pox at six "weeks old, and has undergone the test ot Small-pox inoculation, without taking the disease. A few weeks since at the age of eleven, this boy had casual Small-pox, from wuicli a child was inoculated, and had distinct variolous eruption.
These accidents, occurring nearly at the same period of time, have led to a comparison of the security afforded by ^tnall-pox Inoculation and Vaccination, not disadvantageous to the latter.
On this subject the Report remarks The peculiarities of certain constitutions with regaid to eruptive fevers form a curicus subject for Medical History. Some individuals have been more than once affected with scarlet fever and measles, otheis have been through life exposed to the contagion of these diseases without effect; many have resisted the Inoculation and contagion of Small ?Pox for several years, and have afterwards become susceptible of the disorder, and some have been twice affected with Small-pox. " Among such infinite varieties of temperament it will not appear extraordinary, that Vaccination though so generally successful should sometimes fail of rendering the human constitution unsusceptible of Sqnall-Pox, especially since it has been found that in several instances Small-??x has occurred to individuals over whom the Small pox Inoculation ^ad appeared to have produced its full influence." Ihe varieties of temperament or idiosyncracies here noticed, are very properly said " to form a curious subject of Medical History."" AVith regard to the influence of temperament ?Ver the action of variolous contagion, the history is not only curious but important. Peculiarity of idiosyncracy has given l*ii>e to imam o lies which the ignorant and the prejudiced formerly opposed to Inoculation: arid in the present enlightened time, ^ve see these anomalies produced as arguments against Vaccination. Before the promulgation of Dr. .Tenner's discovery, ln the course of a moderately extensive practice in the casual ar'd inoculated Small-pox, it had happened to us to observe three conditions of the human frame in which Small-pox was ^ her stopped in, or deviated from, its accustomed course, "hese conditions were of opposite properties : they consisted permanent insensibility to variolous Contagion, ol tempo-? jury 23S Critical Analysis. rary insensibility, and of unusual aptitude to rcceive infec-r tion.
We have seen an extraordinary insensibility to the contagion of Small-pox exist permanently, in the eldest sons of one family, and have strong evidence to prove that this peculiarity acted for three generations. That is, the grandfather, we trace no further back, being an eldest son, was insusceptible of variolous Contagion all his days, while the brothers and sisters were, with regard to this disease, as others are.
The eldest son ot this person was also exempted from the effects of this.contagion ; but his brothers and sisters were not.
The eldest grandson enjoyed the same privileges,-but his brothers and sisters all took the disease, either casually, or by inoculation. During the period in which we had an opportunity of observing this family, or hearing its history from the sober and sedate individuals of it, we inoculated, at distant intervals, the last of these privileged persons, four times, without any impression being made on his constitu^ tional invulnerability.
We have seen this insensibility to Small-pox contagion exist for a time only. T. C. a respectable farmer, was inoculated for Small-pox about 1790, with others in the same family. A pustule arose on his arm in the place of the puncture, but continued too short a period, and was unaccompanied with any general derangement or febrile state. He slept with those who had the eruption upon them, but did not take the disease. He was considered to be secure. For twelve years he was occasionally exposed to infection, never avoiding those iu the disease. At the end of this period he was infected, the case was confluent, his eyes were closed ten days, and his life was put into great hazard.
The following instances of unusual susceptibility to the action of the contagion of Small-pox, both casual and inoculated, we know are perfectly correct.
The mother of P. F. had a severe case of Small-pox when this female child, at six months old, was at her breast. The child had the mother's disease in its severest form, was much marked on the face, and lost an eye.
Nineteen years after this we attended the younger branches of this family, some in the casual disease and others under inoculation, to whom this person, P. F*, then between nineteen and twenty years of age, became mirse. During the progress of these cases P. F. sickened with fever, the pustular eruption appeared on the third da}', the crop was large on the face and over the surface generally : she was confined to her bed, the face swelled, and the remaining eye was closed for some days.
1 Report of the National Vaccine Establishment. 939 If this peculiar idiosyncracy which renders a person liable to receive the Small-pox a second time, even in the casual or as it has been called natural Small-pox exists, we shall not be surprized to find some instances of insecure inoculated Small-pox, from the same constitutional susceptibility to re-Ilew the disease. In the course of our professional avocations, WeHhave inoculated upwards of 6000 persons for Small-pox.
Among these we found the individuals of one family, irreguhirly susceptible of the disease. The name of this family was v laylor, and in the daughters only did we perceive this peculiarity. Fourteen years before the time of which we speak, this family was inoculated : they all had the disease with a severity unusual in the inoculated Small-pox. The subjects ?f these remarks, two daughters, had the disease to a degree that marked their faces, and indelible vestigia of the operation remained in their .arms.
The accession of younger branches, and the appearance of Small-pox in the village Where they resided, brought the family again under inoculation. These young women then became nurses to their junior brothers and sisters^ and both again received the disease; not hi the slight and evanescent form in which it has been observed to& occur to nurses, but with active fever, a plentiful crop of pustules, and tumor of the face, though not to absolute closing of the eyes. We could relate a great number of cases wherein Small-Pox, either casual or inoculated, had, within our own know* ledge, succceded to former inoculations. But we consider these to have arisen, generally, from negligent or improper employment of the infecting material; and that the disease Uot having taken place in the first instanbe, these persons Were left the same as if no inoculation had been attempted. In the histories we have given, the facts are marked with a distinctness that shews the actual existence of idiosyncracies, which would if they were sufficiently general, abrogate the established and well understood laws of this disease.
The cases of permanent insensibility to variolous contagion are applicable to vaccination no further, than as they shew the existence of a peculiarity of frame not subjected to the general laws which are known to govern the morbid actions in variola.
The case shewing the existence of a temporary insensibility to variolous contagion, where the person was inoculated While this peculiarity continued, and resisted then and for twelve years afterwards its impression, and at length took the disease in its severest form, applies, by no forced analogy, to the phenomena of Vaccination. If an insensibility to the action of variolous contagion exists for a time, and then subsides. \ 9AQ Critical Analysis. sides, it may surely he allowed that the comparatively mfl? iltiid of the vaccine vesicle may, at one period of time, be, resisted by a similar idiosyneracy, which afterward subsiding may leave the system highly sensible fo.thaf, or to Sina!l-pf>x Contagion; Had the case of Mr. C??occurred,in the early period of Small-pox inoculation, it would have been used shew, the insecurity of that practice.
...... The cases of increased sensibility to variolous contagion, subjecting certain persons to have that disease twice, indiscriminately from either casual or inoculated Si.nail-pox, will shew, very plainly; the fallacy of inferring the insecurity of Vaccination trom solitary instances of Variola occurring after that practice.
It will appear from the preceding statement, the circumstances of which have fallen under our particular cognizance, that one, person in three thousand has received the infection of 5>inalf-pox after what must have been pronounced,successful inoculation. The occurrence of Small-pox.after Vaccination does not, we apprehend, exceed this.ratio. We are aware that a fallacy in conclusion may arise out of the plainest premises. In the present, instance, we go no further in our induction than our own facts warrant. The comparison with failures in Vaccination is an assumption; but we fully believe that Small-pox has not succeeded to Vaccination in the proportion of one in three thousand. . , , , Though our observations on this.short pamphlet have extended beyond the bounds usually allotted to such productions, v we cannot refuse to quote its concluding paragraphs as expressive of the opinions of men whose reputations place them above the suspicion of sinister motives. " The Board a^e of opinion, that Vaccination still rests upon the basis on which it was placed, by tne Reports of the several Colleges of Physicians and Surgeons of the United Kingdom, which were laid before Parliament in the year 1807-That the general ad vantages of Vaccination are not discredited by theinstances of failure which have recently occurred, the proportion of failures still remaining less in number than the deaths which take place from the Inoculated Small-pox. They are led by their information to believe, that since this practice has bten fully established, no death has in any instance occurred from Small-pox after Vaccination? That, in most of the Cases in which Vaccination has failed the Small-pox has been a disease remarkably mild, and of unusually short duration; and they are further of opinion, that the severity of the symptoms with which Mr. Grosvenor was affected, forms an exception to a general rule.
That absolute security from the natural Small-pox is not even to be obtained by Small-pox Inoculation, is sufficiently evident from the annexed Cases, and the board are enabled to state, that they have been made acquainted with instances of individuals who have twice undergone the natural Small-pox. i Under Dir. Hutchison on Popliteal Aneurism, S, c. Si I Under all these circumstances, the Board feel justified in still recomending and promoting Vaccination, and in declaring their unabated onlidence in this practice.?Since, in some peculiar frames of Consti-Ut!on' the/repetition of Small-pox is neither prevented by Inoculation or casual infection, the Board are of opinion that in such peculiar cong Uut10ns> the occurrence of Small-pox after Vaccination may be rea-|na ly expected, and perhaps in a grtater proportion, but with this adof \?n t'le^r not ^les'tatc to maintain, that the proportionate advantages ''ccination to individuals and the public, are infinitely greater than ^ma^'Pox Inoculation. hey are anxious that the existence of certain peculiarities of the ^ame, by which some individuals are rendered by nature, more ess susceptible of eruptive fevers, and of the recurrence of such disc ers, should be publicly knovvri; for they feel confident that a due 0p '?'deration of these circumstances, and a just feeling of the welfare y tie Community, will induce the public to prefer a mild disease like Ration, which where it fails of superseding the Small-pox, yet eff *>ates Its violence, and prevents its fatal consequences, to one whose ^?upare frecluent,y violent, to one which often occasions deformity blindness, and when it is contracted by casual infection, has been pposed to destroy one in six in all that it attacks. And it must not be j?'gotten, that in a public view this constitutes the great objection to noculation of the Small-pox, that by its contagion it disseminates death 'oughout the Empire, whilst Vaccination, whatever be the compara-Ve security which it affords to individuals, occasions no subsequent . . ?rcter$ and has never by the most violeilt of its opposers been charged producing an epidemical sickness.
Letter respectfully addressed to the Commissioners for '  Hunter, but the operation has been improved since his time. In cutting down upon the inner margin of the Sartorius, the Vena saphena major will generally be divided, as will the principal lymphatics of the leg. Two inconveniences will arise from the division of these vessels. The flow of blood from the vein will greatly embarrass the operator, and the discharge of lymph will retard the healing of the wound. To avoid these accidents, it has been proposed to cut upon the artery by the outer margin of the Sartorius. Mr. Charles Bell first advised this method of bringing into view the femoral artery, but assigned no reason for it. Dr. Hutchison briefly states it? advantages.
" There are no large veins or lymphatics in the way of the knife and the operation will be finished in as short a time, with as little pai?
to the patient, and certainly with much greater satisfaction to the operator, from his not being embarrassed by haemorrhage*; a circumstance so frequently occurring, when operating on the part as directed by Mr*